COPAY PLAN HDHP W/ HSA Employer HSA Contributions N/A +$1,000 Annual Contribution Deductible (Single/Family) $2,500/ $5,000 $4,000 / $8,000 Coinsurance 20% 0% Out-of-Pocket Max (Single/Family) $6,350 / $12,700 $4,000 / $8,000 Physician/Specialist Visits $50 / $75 Copay 0% After Deductible Preventive Care 100% Coverage 100% Coverage Hospital/Out-Patient 20% After Deductible 0% After Deductible Emergency Room $500 Copay 0% After Deductible Urgent Care Centers $75 Copay 0% After Deductible MEDICAL PLAN OPTIONS